Tameside & Glossop Business Group
Community Infection Prevention Service
Selbourne House
Union Street,
Hyde,
Sk1 1NG
Tel: 0161 366 2321/20
Fax: 0161 366 2385
Date:
E-mail: collette.saunders@nhs.net
Dr :
GP address
Dear Dr
Re:
Patients name:
DoB:
NHS No:
A recent laboratory sample indicated that your patient tested positive for Clostridium
difficile colonisation. Organisms that were present in the large bowel were Glutamate
Dehydrogenase (GDH) positive, but the Clostridium Difficile Toxin (CDT) test was
negative.
Please can you record the READ code ‘AJQ2’ against this patient’s electronic patient
record?
Although there was no laboratory evidence of Clostridium difficile enteric infection, your
patient may be at risk of developing Clostridium Difficile Toxin (CDT), a healthcare
associated infection (HCAI), often associated with antibiotics. If diarrhoea persists, and
CDT is suspected, further samples are not indicated but antibiotic treatment may be
required.
To assist you with the management of this and other patients, please refer to the
attached advice sheet from the Microbiologist at Tameside NHS Foundation Trust.
If you require information on the nursing management of this patient, please contact the
Community Infection Prevention Service Team on telephone no. 0161 366 2320/21.
For further medical information or support, please contact Dr Howard Sacho, Consultant
Microbiologist, on telephone no. 0161 922 4086 or via the Tameside NHS Foundation
Trust hospital switchboard.
Yours sincerely
Collette Saunders
Clinical Lead for Infection Prevention
Tameside NHS Foundation Trust
Department of Microbiology
Glutamate Dehydrogenase (GDH) positive, Clostridium Difficile Toxin (CDT) negative diarrhoea
This indicates that the patient is colonized with Clostridium difficile organisms in the large bowel, but there is no
laboratory evidence of Clostridium difficile enteric infection and therefore antibiotic treatment is NOT indicated.
However, if the patient has features suggestive of Clostridium difficile enteric disease including profuse
diarrhoea, abdominal tenderness, dehydration with electrolyte disturbance, renal impairment, hypotension,
leukocytosis or pyrexia, then empiric antibiotic treatment for Clostridium difficile infection is warranted.
Please add a Read Code 4JQ2 alert to this patient's records to indicate that they have had Clostridium difficile
colonization in order that prescribers in the future can be suitably cautious re the prescribing of antibiotics.
Please also inform any other health care providers of the Clostridium difficile diagnosis as appropriate at the point
of referral, and notify GO to DOC for their information.
Clostridium difficile associated diarrhoea (CDAD)
Up to 30% of patients develop recurrences of Clostridium difficile diarrhoea after initial treatment with either oral
Metronidazole or oral Vancomycin. There is a 65% incidence of second and subsequent relapses in patients who
have experienced a first recurrence of Clostridium difficile diarrhoea. Patients over the age of 65 years are
particularly at risk of relapse. The risk of relapse can be reduced by “Antibiotic Stewardship”, which means that
antibiotics are used to treat bacterial infections, administered at the most appropriate dosage, given for the most
appropriate duration and are not given to fill a diagnostic hiatus.
There is no such thing as an “antibiotic course” for the treatment of the vast majority of infections. Exceptions, in
which antibiotic treatment should be continued for a number of weeks include: infective endocarditis,
osteomyelitis / septic arthritis, lung abscess. As a guideline, once the patient has become apyrexial, has
defervesced and is clinically improving, continue treatment for:
• 2 more days in the immunocompetent patient and then stop.
• 3 more days in the immunosuppressed patient (including those who initially presented with neutropenic
sepsis but whose neutrophil count is returning to normal levels), and then stop.
In general, most antibiotic treatments should not exceed 5 days and treatment durations of 2, 3 or 4 days may
be entirely adequate. Assessment of the patient's clinical response to antibiotic treatment should include:
•
•
•
•
Improvement or resolution of symptoms and signs of infection (such as pyrexia, haemodynamic
instability and hypotension, and mental confusion).
Microbiologic tests indicating that the organism has been eliminated from the body
Chemistry and haematology results (such as white cell count, CRP, renal and hepatic function) which
are returning to normal or have returned to normal parameters.
Radiological improvement or resolution.
Caution with the use of proton pump inhibitors (PPIs) is advised and if not indicated should be stopped.
In the event of relapse occurring in your patient, mild to moderate diarrhoea (stool frequency of < 3 stools /day,
small amounts, no pyrexia, no abdominal tenderness or distension, no hypotension) can be managed with
1. Probiotic drinks (Actimel 100ml, orally before meals twice daily for 10 days)
2. Cautious use of anti-motility agents (eg. Loperamide 2mg stat, followed by 2mg prn, for 1-2 days to a
maximum of 6-8 mg / day)
Should treatment prove necessary as per para 2 above, the protocol is as follows:
1)
Mild or resolving cases:
No antibiotic treatment.
2)
First episode, first relapse or moderate diarrhoea:
Metronidazole 400 mg po tds (or 500 mg 8 hourly IV) until the diarrhoea has resolved or is resolving, but
can be continued for up to 10 days
3)
Subsequent relapses/unresponsive to metronidazole:
Rifaximin 400 mg po tds until the diarrhoea has resolved or is resolving, but can be continued for up to
10 days
Unresponsive to Rifaximin:
Vancomycin 125 mg po (not IV) qds until the diarrhoea has resolved or is resolving, but can be
continued for up to 10 days
4)
You may be aware that there is no recommended standard treatment for multiple recurrences. Long and
repeated courses of oral metronidazole should be avoided because of adverse effects including neurotoxicity,
peripheral neuropathy, seizures and leucopenia. The use of oral vancomycin is also discouraged for the
treatment of mild to moderate cases of Clostridium difficile diarrhoea.
For further information or support, contact me on 0161 922 4086 or via the hospital switchboard.
Dr Howard Sacho
Consultant Microbiologist
2012